Atrial fibrillation

Question 1

when is a surgical MAZE procedure done for afib?

Answer 1

only if the pt is undergoing a cardiac surgery for other indications (cabg or valve replacement)

Question 2

paroxysmal afib is

Answer 2

<7 days of two or more episodes of afib that terminate spontaneously or with intervention .

PAF will have recurrent symptoms ranging from 70% to 90% at four years

Question 3

amiodarone side effects:

Answer 3

hepatotoxicity

thyroid disfunction

interstitial lung disease

peripheral neuropathy

Question 4

preferred antiarrhythmic therapy for people with Afib if they have: heart failure

Answer 4

amiodarone or dofetilide (tikosyn)

Question 5

indications for radiofrequency catheter ablation for afib

Answer 5

AV nodal reentrant tachycardia (AVNRT) AVRT - atrioventricular reentrant tachycardia focal atrial tachycardia a flutter (preferred over drug therapy) a fib (if failed drug therapy) sympomatic WPW syndrome sustained HDS monomorphic VT

Question 6

when to add AC for a patient with a fib

Answer 6

CHADSVASC 2 or more for men

3 or more for women

CHF

HTN

Atherosclerosis - CAD

DM2

Vascular dx (PVD, oprior MI, aortic plaque)

AGE 65-74

2 points for Stroke or TIA

SEX

Question 7

how to treat someone who has multiple GI bleeds on AC (wafarin, rivaroxaban and apixaban) and has a fib?

Answer 7

see if they qualify for atrial appendage occusiion (watchman)

still recommended to have AC for first 45 days after procedure.

Question 8

preferred antiarrhythmic therapy for people with Afib if they have: LVH

Answer 8

dronedarone or amiodarone (class 1 c)

Question 9

if afib >48 hrs and want to do a electrical cardioversion

Answer 9

needs a TEE to rule out left atrial thrombus prior to chemical or electrical cardioversion.

Question 10

side effects of procainamide:

Answer 10

see drug induced lupus can see agranulocytosis, thrombocytopenia and neutropenia after 3 months of use can see fatigue, fever, nausea and rash (with agranulocytosis) see anorexia vomiting headaches, depression dizziness and Raynaud’s

Question 11

mitral stenosis and afib

Answer 11

has underlying rheumatic dx and needs to have warfarin for INR goal of 2-3.

DO NOT USE CHADS2 or CHADSVASC (that’s for non valvular afib)

Mitral stenosis and a fib has a high chance of embolism; up to 15%

Question 12

underlying causes of atrial fibrillation

Answer 12

sepsis, hypoxia, congestive heart failure, poorly controlled HTN hyperthyroidism anemia ACS valvular disease

Question 13

criteria for anticoagulation with mitral stenosis

Answer 13

1 or more of the following:

paroxysmal, persistent and permanent AFIB

prior embolic event

left atrial thrombus

Question 14

role of digoxin in treatment of afib

Answer 14

helpful for controlling AFIB with RVR and has heart failure. Not used to help with rhythm control and not used for prevention of recurrences with PAF.

Question 15

rate control medications

Answer 15

beta blockers, CCB and digoxin

Question 16

other systemic causes of afib

Answer 16

alcohol,

sepsis,

hyper/hypothyroidism,

obesity

Question 17

DOACs are better than warfarin because

Answer 17

they have similar or reduced rates of ischemic stroke and reduced risk of major bleeding in pts with afib and CKD with GFR >30

no lab checks

fewer drug-drug interactions

fewer food interactions

NOT ok for cirrhosis or chronic liver dx, BMI >40, pregnant pts

Question 18

If pt has paroxysmal afib with mitral stenosis what do you do?

Answer 18

she needs to be started on warfarin, even if age is 30 yrs old and no other CHADSVASC risk factors. Do not use CHADSVASC for assessment Fact that she has mitral stenosis and Afib is enough since there’s a high risk of systemic VTE.

Question 19

beta blockers side effects:

Answer 19

heart failure heart block

hypotension

also see diarrhea,

bronchospasm (always use beta specific),

sexual dysfunction and ED

Question 20

pt with afib new severe periumbilical pain that is out of proportion to physical exam and see leukocytosis and elevated amylase and metabolic acidosis with elevated lactate levels you need to consider

Answer 20

acute mesenteric ischemia

Question 21

preferred antiarrhythmic therapy for people with Afib if they have: CAD without heart failure

Answer 21

sotalol or dronedarone

Question 22

what kind of anticoagulation should be used for mitral stenosis and afib?

Answer 22

only warfarin.

newer DOACs are for non valvular afib.

Question 23

what must be done prior to an electrical or pharmacological cardioversion with afib? management after cardioversion?

Answer 23

if >48 hrs needs to get a TEE to rule out a left atrial appendage thrombus. after cardioversion needs 4 weeks of AC to minimize risk for systemic thromboembolism due to stunning of atrial with cardioversion

Question 24

“pill in the pocket afib” tx

Answer 24

propafenone and flecainide - used for pts who have no structural heart dx

meant for people who have infrequent episodes of paroxysmal a fib to convert back to sinus rhythm.

need to take beta blocker or dilitiazem if they aren’t on one already,

take BB 30 minutes prior to taking a single dose of propafenone or flecainide pill to prevent Aflutter with RVR

Question 25

dofetilide (tikosyn) complications

Answer 25

can cause torsades de pointes

need to be monitored for at least 3 days with telemetry and lab checks

remember your “tikosyn prisoner”

Question 26

for pts who are >65 years and those with heart failure this is our preferred management route:

Answer 26

rate control over rhythm control because of less side effects with rate control compared to rhythm control from anti-arrhythmic drugs

Anti-arrhythmics have greater risk for torsades de pointes and more risk for pulm, thyroid, and visual toxicities.

Question 27

if there is a left atrial appendage thrombus and no electrical cardioversion can be done with a pt who has afib, what to do next?

Answer 27

AC for >3 weeks prior to cardioversion.

Question 28

why do we prefer rhythm control in pts <65 yrs old

Answer 28

because lower risk of proarrhythmias like torsades de pointes in younger pts without comorbidities and provides greater exercise tolerance.

Question 29

anticoagulation for afib with a patient who has a higher bleeding risk after a stent placement

Answer 29

plavix + DOAC

NO triple therapy of ASA + plavix + DOAC or at least triple therapy for a month then stop aspirin and continue plavix + DOAC

Question 30

pulmonary causes of afib:

Answer 30

COPD,

PE,

OSA,

acute hypoxia

pneumonia

Question 31

rhythm control treatment in symptomatic a fib tx:

Answer 31

antiarrhythmics are preferred over catheter ablation but catheter ablation for AF is treatment of choice for people who failed antiarrhythmic therapy- failed two

Question 32

Drugs that can cause afib

Answer 32

theophylline and amphetamines

Question 33

Pt who gets cardioverted for unstable afib with RVR should get

Answer 33

at least 4 weeks of AC post cardioversion to prevent any risk for thromboemolism/stroke.

This lowers risk for stroke to 1%

long term anticoagulation is determined based on pt’s thromboembolic risk and bleeding risk profile.

Question 34

preferred antiarrhythmic therapy for people with Afib if they have: recurrent afib refractory to medication

Answer 34

radiofrequency ablation

Question 35

cardiac reasons for a fib to develop:

Answer 35

hypertensive heart dx,

rheumatic or valvular heart dx,

CHF,

post cardiac surgery

CAD

Question 36

If someone is in afib when to add amiodarone?

Answer 36

after pt is therapeutic on AC for 3 weeks or if TEE is done to rule out presence of clot.

This is because after starting there is a chance of chemical cardioversion.